While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?

Monitor I&O

Check blood pressure

Assess pain level

Measure oxygen saturation

Answer and Explanation

The Correct Answer is B

A)   Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B)   Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C)   Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D)   Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.

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Correct Answer is A

Explanation

A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.

B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.

A. Impaired pancreatic enzyme production B. Presence of viral infection C. Hyperlipidemia D. Increased vascular permeability

Correct Answer is A

Explanation

A) Chronic pancreatitis can lead to a decrease in enzyme production necessary for digestion, leading to malabsorption.
B) This does not typically cause malabsorption associated with chronic pancreatitis.

C) While it can occur with chronic pancreatitis, it does not directly cause malabsorption.
D) This is not related to the digestive malabsorption seen in chronic pancreatitis.

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While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Correct Answer is A

Explanation

The nurse is caring for a client with chronic pancreatitis who exhibits signs of malabsorption. The nurse recognizes that this is due to which pathophysiology process?

Correct Answer is A

Explanation

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